Physicians are using pulmonary artery (PA) catheterization at an increasing rate in heart failure patients, despite results from the ESCAPE trial that showed an increase in adverse events without improving outcomes in heart failure patients who had PA catheterization added to standard management.

“These findings suggest a potential opportunity for improvement in quality of care and reduction in health care cost among patients hospitalized with acute heart failure,” Dr. Gregg C. Fonarow from Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, California told Reuters Health by email.

“Additional research is needed to identify factors responsible for the observed increase in use of PA catheters among heart failure patients and determine whether integration of clinical decision support based on appropriate use criteria can improve heart failure care quality and value,” he added.

Based on results from the 2005 ESCAPE trial, the American College of Cardiology-American Heart Association guidelines discourage the use of PA catheters in routine management of heart failure.

Dr. Fonarow and colleagues examined contemporary trends in the use of PA catheterization in nearly 2.5 million adult patients with a primary diagnosis of heart failure in the National Inpatient Sample.

The use of PA catheters declined from 7.9 per 1,000 heart failure hospitalizations in 2001 to 4.9 per 1,000 heart failure hospitalizations in 2007, but thereafter increased steadily to 7.9 per 1,000 heart failure hospitalizations in 2012.

Results were similar in the subgroups of patients with cardiogenic shock and patients without cardiogenic shock or mechanical ventilation requirements, according to the November 30 JAMA Internal Medicine online research letter. In contrast, PA catheterization rates declined consistently among patients with respiratory failure.

“These findings suggest that at least some of the PA catheter use in hospitalized heart failure is inconsistent with current clinical trial evidence and current ACC/AHA guidelines,” Dr. Fonarow said.

“Some strategies for improvement include greater education of physicians about guideline recommendations regarding the use of such invasive strategies and incorporation of additional clinical decision support tools in day-to-day care of heart failure patients to assist physicians with real-time guidance about the appropriateness of invasive monitoring,” he said.

Dr. Derek C. Angus, from the University of Pittsburgh in Pennsylvania, who wrote an invited commentary related to this report, told Reuters Health by email, “There tends to be a reticence to hold diagnostic strategies to the same level of evidence as therapeutics. But diagnostic strategies can be both expensive and dangerous in their own right (especially if invasive) and can generate downstream consequences due to the actions they prompt with their results, not all of which are necessarily beneficial. Thus, I think physicians do need to demand evidence of net benefit from diagnostic strategies, including those that are already ‘available’ in practice.”

“I can appreciate that there may be occasional patients in whom one has a strong sense that better information about central pressures and so forth will aid decision-making and care,” Dr. Angus said. “However, if the rate is genuinely rising, then I would like to see proponents for its use articulate ‘how’ it should be used and, ideally, ‘prove’ the benefit in a randomized controlled trial.”

The authors reported no funding. Dr. Fonarow reports receiving research support from the Agency for Healthcare Research and Quality and the National Institutes of Health and serving as a consultant for Amgen, Bayer, Gambro, Novartis, and Medtronic.